Clinician competencies: Strengths and limitations for work with transgender and gender non-conforming (TGNC) clients

Individuals who identify as transgender or gender nonconforming (TGNC) face a number of health disparities compared to individuals who identify as cisgender (those who self-identify with the sex they were assigned at birth). For example, TGNC individuals experience heightened rates of clinical depression, anxiety, general psychological distress, suicidal ideation, and suicide attempts. Despite these troubling disparities, many TGNC individuals report hesitance to seek mental health services due to concerns regarding culturally insensitive or even overtly discriminatory services from providers. In addition to decreasing service utilization among TGNC populations, discriminatory services impair intervention effectiveness even when TGNC individuals persist in seeking mental health services. The American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) provide guidelines for culturally competent work with TGNC clients; however, research indicates a profound lack of TGNC-specific training and resources among mental health care providers. To address this gap, the present investigation utilized a mixed-method design to assess training experiences, understanding of terminology, and TGNC competence among mental health care providers at various training levels. Participants were current mental health clinicians across the United States. Implications for improving reported and demonstrated weaknesses are discussed.     

The Counseling Experiences of Transgender and Gender Nonconforming Clients

The counseling experiences of 13 transgender and gender nonconforming (TGNC) individuals were examined via semistructured, in‐depth interviews. Using multiple standards of trustworthiness (e.g., member checking, negative case analysis), the authors analyzed each interview from an interpretative phenomenological analytic framework. Four main themes were identified: mental health professional selection process, transaffirmative approach, transnegative approach, and support systems beyond counseling. Implications for implementing culturally responsive TGNC affirmative counseling, TGNC sensitive counselor training, and social justice–oriented research are discussed.     

Transgender and gender non-conforming adult preparedness for aging: Concerns for aging,and familiarity with and engagement in planning behaviors

Abstract

Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity.

Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity.

Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs.

Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals.

Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.     

Intake Interviewing with Lesbian, Gay, Bisexual, and Transgender Clients: Starting from a Place of Affirmation

Initial interactions between lesbian, gay, bisexual, or transgender (LGBT) clients and psychotherapists can reveal existing biases from both parties. LGBT clients may have previous experiences with the mental health establishment and legitimate concerns about being pathologized. Psychotherapists may approach clients with openness and acceptance, but are likely to have little training in working with LGBT individuals. In this article, we discuss affirmative practices as a framework for clinicians beginning the intake process with LGBT clients. Through a brief history and overview of LGBT mental health, we provide mental health professionals with an appreciation of the multiple influences on LGBT individuals’ well-being. We then discuss the intake interview process in relation to each subgroup of the LGBT acronym, as each of these four populations face different (yet inter-related) challenges. While there is clearly no “formula” for working with LGBT individuals, in keeping with the principles of multicultural competency (Sue, The Counseling Psychologist, 29:790–821, 2001), our goal is to encourage therapists to reflect on their existing biases and to gain knowledge and skills for working with this diverse population. Overall, we hope this article demonstrates to therapists how to conduct an affirmative intake interview that minimizes heterosexual and dualistic gender assumptions that remain so pervasive in our society and in therapeutic practice.     

The experiences of transgender and non-binary children and young people and their parents in healthcare settings in England,UK: Interviews with members of a family support group

Abstract

Background: Transgender and non-binary children and young people and their parents in England, UK are poorly served across a range of healthcare settings. Whilst UK equalities legislation and international guidance on transgender healthcare pathways protects this group from discrimination and mandates an affirmative approach, services in England are not keeping pace.

Aims: This study aims to draw on the experiences of transgender and non-binary children, young people and their parents in a support group in England in order to investigate their experiences of healthcare provision, and to develop some ideas for improvement.

Method: Data was collected with participants in a family support group which offers a parent helpline service, social groups for children and parents, and training for schools and other organizations. 65 parents and children from 27 families from the family support group attended participatory workshops where they were given a range of briefs: “health,” “family,” “friends,” and “education.” Their participation involved being asked to define their own interview questions and collect data by interviewing each other. Their interview notes constituted the raw data. Data was coded inductively by the author with respondent checking as a second stage.

Results: Results constitute the views of a small group of people, so cannot be generalized. However, they do illustrate some of the issues which may arise. Participants’ experiences elicited five key themes: professionals’ perceived lack of clinical and therapeutic knowledge; mental distress caused by excessive waiting lists; professionals’ stereotyped gender assumptions; direct discrimination within healthcare settings; and a lack of attention to parent and child voice, especially in terms of school-based experiences and where a patient had a diagnosis of autism.     

How well do various types of support buffer psychological distress among transgender and gender nonconforming students?

Background: Transgender and gender nonconforming (TGNC) individuals experience an increased prevalence of many psychological disorders, leading many to reach out for support from family, friends, mental health professionals, and religious or community networks. Nonetheless, experiences seeking support are often negative, and many psychotherapists report feeling underprepared to work with TGNC clients. To better understand the experiences of TGNC individuals and better equip psychotherapists in their work with TGNC clients, we investigate which sources of support most successfully buffer psychological distress among TGNC individuals.

Aims: This study aims to identify differences in levels of various types of support (social, family, religious, and living-situation) between cisgender and TGNC individuals and examine how these types of support may or may not buffer psychological distress among TGNC individuals.

Method: We used a United States national sample of 3,090 students (1,030 cisgender men; 1,030 cisgender women; 349 transgender; 681 endorsing another gender identity) from the Center for Collegiate Mental Health 2012–2015 database which provided basic demographic information through the Standardized Data Set. Psychological distress was measured through the Counseling Center Assessment of Psychological Symptoms 34-item questionnaire.

Results: TGNC individuals reported more distress, less family support, more social support, and less frequent religious affiliation than cisgender men and women. Family and social support emerged as the strongest predictors of distress for both TGNC and cisgender individuals. Though religious affiliation and living on-campus buffered distress among cisgender students, they did not buffer distress among TGNC students.

Conclusion: Our study highlights disparities in distress and support between TGNC and cisgender individuals. We found that although religious affiliation and on-campus living are beneficial for cisgender students, neither systematically buffers distress for TGNC students. These findings illustrate the impact minority stress and systemic discrimination may have on TGNC individuals and provide suggestions for therapeutic intervention in work with TGNC individuals.     

Suicide and the Law

SUMMARY

The purpose of this chapter is to delineate how mental health professionals can prevent their clients from acting in a suicidal manner while protecting themselves against potential liability when a client attempts or completes suicide. In our increasingly litigious society mental health professionals can apply their understanding about the elements of legal liability in cases involving client suicidal behaviors to structure their services in a manner to meet their responsibility in treating potentially suicidal clients.     

Internalized transphobia: Exploring perceptions of social messages in transgender and gender-nonconforming adults

Background: Transgender and gender nonconforming (TGNC) individuals encounter a variety of minority stressors that have yet to be fully articulated or explored within the research literature. The purpose of this study is to better understand internalized stigma—the experience of accepting and internalizing negative social messages and experiences about one's identity—an underexplored minority stressor for TGNC people.

Method: We conducted in-depth interviews with 30 diverse TGNC participants using consensual qualitative research (CQR) methodology.

Results: Following data saturation and analysis, six distinct themes emerged across participants: (1) TGNC identities are regarded negatively by society; (2) social messages are perceived as originating from the media and religious ideology; (3) TGNC individuals report emotional distress; (4) negative self-perceptions in response to social messages; (5) TGNC individuals report resilience processes in response to negative social messages; and (6) social messages are perceived generally to differentially impact TGNC people of color.

Conclusion: Findings highlight the common experience of encountering social marginalization for TGNC individuals. Structural interventions that target pervasive sociocultural messages regarding TGNC identities are warranted.     

Beyond the Binary: Trans‐Negotiations in Couple and Family Therapy

Dualistic notions about gender and sexuality have permeated the field of couple and family therapy. These binary constructions have been limiting for everyone, especially those who fall outside the male/female dichotomy. This article examines the impact of these binary notions, especially on transgender and gender‐creative individuals, couples, and families. Current theory and research in the field as they relate to gender identity, sexuality, and gender minority stress in couples and families are presented. Case examples are used to illustrate affirmative approaches to treatment issues such as coming out, safety, grief and loss, redefining relationships, and social/medical transitions that may arise for transgender or gender nonconforming (TGNC) individuals, couples, and families.     

Examining Factors Associated with Primary Care and Continuity of Care Among Adults with Severe Mental Illness

A number of studies have consistently reported that there is a greater prevalence of mental illness among the most socioeconomically disadvantaged. At the same time, there is evidence that services are not optimally accessed by the most socioeconomically disadvantaged; the most in need of care are also the most likely to have unmet healthcare needs. Of people with mental illnesses, those with severe mental illnesses (SMI) are the most at risk of poverty and the least likely to have optimal care. In the past, specialized community mental health services have been identified as the primary provider for people with SMI. However, there is growing interest in using the primary care setting as the main source of mental health care where both medical treatment and psychotherapy can be accessed. In this paper, we examine factors related to primary care use (and in turn, pharmacologic and psychotherapies) for people who are socioeconomically disadvantaged and who have a SMI.     

Factors Predicting the Inclusion of Lesbian,Gay, and Bisexual Affirmative Content Taught in Couple and Family Therapy Courses

Abstract

This study explored the relationship between Couple and Family Therapy (CFT) faculty members’ Lesbian, Gay, and Bisexual (LGB) clinical competence and the level of LGB affirmative therapy content they teach in their courses. Hierarchical regression analyses of 117 faculty in accredited CFT programs suggest that faculty members’ own reported competence to work with LGB clients predicted their inclusion of LGB affirmative course content in the courses they teach. Important gender effects also emerged suggesting that women faculty are more likely than men to teach LGB affirmative course material. Results suggest important implications for CFT faculty, training programs, and accreditation standards.     

The Mental Status Examination: Its Use by Professional Counselors

Although not a formal psychometric instrument, the mental status examination (MSE) has been used predominantly in psychiatry, clinical psychology, and social work for several decades, but is being increasingly used by counselors in work settings requiring assessment, diagnosis, and treatment of mental disorders. The MSE is used to obtain information about the client's level of functioning and self‐presentation. Generally conducted (formally or informally) during the initial or intake interview, the MSE can also provide counselors with a helpful format for organizing objective (observations of clients) and subjective (data provided by clients) information to use in diagnosis and treatment planning.     

Referrers' Perceived Utility and Outcomes of Clinical Neuropsychological Assessment in an Adolescent and Young Adult Public Mental Health Service

Despite frequent informal or anecdotal acknowledgement of the usefulness of neuropsychological services within various settings, including mental health settings, few studies have formally investigated the satisfaction, perceived utility, or outcomes associated with such a service. This survey‐based study evaluated referring clinicians’ (n = 35) perceptions of the usefulness and outcomes associated with the provision of clinical neuropsychological assessment and feedback within an adolescent and young adult public mental health service in Melbourne, Australia. The results suggest that referrers perceive the neuropsychological service, including formal neuropsychological assessment report and verbal and written feedbacks, as a highly useful adjunct to their clinical practice. In addition, referrers frequently reported clinically meaningful outcomes in association with the neuropsychological service, including diagnostic changes or additions (11% of clients referred), changes to approaches in treatment (52% of clients referred), and increased or appropriate access to services, education, or work (33% of clients referred). Referrers also reported that almost 60% of neuropsychological assessment reports were forwarded to other services or clinicians involved in the client's care. The findings suggest that mental health settings are likely to benefit from routine inclusion of specialist neuropsychology services. However, future research should also examine client and family perceptions regarding the satisfaction and usefulness of neuropsychological services.     

Treatment rights of the mentally retarded: The cost of refusal

The cost of the mentally retarded client's rights to refuse treatment, in both monetary and human terms, varies under different legal/clinical circumstances. The process of placing severely retarded clients into the community with poor or no supervision, especially those who refuse or are denied treatment, can result in devastating costs for the client and others. The complexities associated with mental retardation require sophisticated treatment considerations. Moreover, these clients often need guidance in making meaningful decisions relevant to their quality of life. In order for this process to produce desirable results, for both the mentally retarded client and society, in general, a balance must be struck between the legal and clinical factors involved.     

Health and Social Services for Male-to-Female Transgender Persons of Color in San Francisco

SUMMARY

This article presents findings from an investigation of health needs, service utilization, and perceived barriers to services among male-to-female (MtF) transgender persons of color in San Francisco. Focus groups (n = 48) and survey interviews (n = 332) were conducted with convenience samples recruited from the community. Participants reported a range of health and social services needed during the previous year, with African-Americans and Latinas showing particularly strong service needs. Rates of utilizing services were high for basic health care but lower for social services, substance abuse treatment, psychological counseling, and gender transition-related medical services. No significant ethnic group differences in health service utilization were found. Qualitative findings evinced the call for transgender-specific programs and advanced provider training on transgender issues such as hormone use, gender transition, HIV/ AIDS care and prevention, substance abuse, and mental health problems.     

The use of superficial and meaning-based representations in interpreting pronouns: Evidence from Spanish

Abstract

In this paper, we address the question of whether a representation of the surface form of a text is directly implicated in the interpretation of definite pronouns in that text. According to an influential theory proposed by Sag and Hankamer (1984), it should not be, because definite pronouns are model-interpretive anaphors that take their meaning from elements in a representation of content. We report three experiments in Spanish, a language with non-semantic gender, in which pronouns can match their antecedents on the basis of morphosyntactic properties alone. The first experiment suggested that a surface representation might not be implicated in the interpretation of pronouns, since a gender match speeded only the interpretation of pronouns referring to people and not those referring to things. However, a questionnaire study (Experiment 2) confirmed that our strategy of modelling the Spanish sentences in Experiment 1 on sentences used in English studies had affected the results, and a further on-line experiment provided evidence that the interpretation of pronouns referring to things can be speeded by a gender match (Experiment 3). We discuss the implication of these findings for theories of text comprehension.     

Genetic Information,Non-Discrimination,and Privacy Protections in Genetic Counseling Practice

The passage of the Genetic Information Non Discrimination Act (GINA) was hailed as a pivotal achievement that was expected to calm the fears of both patients and research participants about the potential misuse of genetic information. However, 6 years later, patient and provider awareness of legal protections at both the federal and state level remains discouragingly low, thereby, limiting their potential effectiveness. The increasing demand for genetic testing will expand the number of individuals and families who could benefit from obtaining accurate information about the privacy and anti-discriminatory protections that GINA and other laws extend. In this paper we describe legal protections that are applicable to individuals seeking genetic counseling, review the literature on patient and provider fears of genetic discrimination and examine their awareness and understandings of existing laws, and summarize how genetic counselors currently discuss genetic discrimination. We then present three genetic counseling cases to illustrate issues of genetic discrimination and provide relevant information on applicable legal protections. Genetic counselors have an unprecedented opportunity, as well as the professional responsibility, to disseminate accurate knowledge about existing legal protections to their patients. They can strengthen their effectiveness in this role by achieving a greater knowledge of current protections including being able to identify specific steps that can help protect genetic information.     

Australian lawyers' views on competency issues in older adults

Lawyers are often called upon by their older clients to draft contracts, make up wills or powers of attorney, or provide other forms of legal advice or service. With the increasing numbers of older people in the population, the numbers of older clients for legal practitioners is likely to increase. Older people are also at increased risk for impaired cognitive processes that can affect their ability to make reasoned judgements in civil contracts and other legal arrangements. Here we report on the results of a survey of 302 Australian solicitors as to their experience and practices in determining the capacity of older clients to make legal decisions. The responses, reflecting a 20.7% return rate, showed a wide range of experience in conducting capacity assessments, with a mean of 15.7 years (SD = 10.59). There was a very wide range of practices in determining capacity with no consensus. The most frequent form of questions older clients were asked related to personal and family history. Less than one-quarter asked for the rationale of the decision: the most appropriate form of question in the literature. The results suggest a need for further training of solicitors in the assessment of the capacity of older clients to make legal decisions.     

Philosophical Counselling, Truth and Self-Interpretation

Philosophical counselling, Ran Lahav and others claim, helps clients deepen their philosophical self-understanding. The counsellor's role is the minimalist one of providing the client with the philosophical tools needed for reflective self-evaluation. Respect for the client's autonomy entails refraining from intervening with substantive moral criticism, theories, and methods; the client's ways of working out fundamental questions like ‘Who am I and what do I really want?’cannot be assessed by the counsellor in terms of their truth-value, but only in terms of whether they reflect the client's autonomous choice to express him/herself in a certain way. I argue that this view, which is informed by an anti-realist account of self and life-history, undermines the distinction between self-knowledge and self-deception. Once interpretive and criteriological free rein is given to the client, and once personal, pragmatic and aesthetic considerations take precedence over truth-value, then the way is left open to clients to generate the most morally convenient self-interpretation to suit their current needs. I defend the view that truth matters in philosophical counselling; more specifically, that there is a basic distinction between true and false forms of self-understanding. To do this, I offer a broadly realist account of self and reflective self-evaluation. If this is right, then philosophical counsellors shoulder a significant burden of responsibility in helping their clients achieve an accurate, defensible, action-guiding and truth-oriented self-understanding.